Questionable Hope for CCSVI in Multiple Sclerosis

May 12, 2011

Once again, multiple sclerosis patients’ area buzz over a new theory and treatment for the disease. The theory is called chronic cerebrospinal venous insufficiency (CCSVI); and, this time, social media is driving the patient excitement.

CCSVI is based on a controversial idea that impaired venous drainage of the brain due to blockage in venous structures causes MS. Increase in venous pressure promotes leakage of blood across capillaries, with inflammation resulting from the iron deposition into the brain. In 2009 Paolo Zamboni, M.D., reported that virtually all MS patients in a study had abnormalities in the jugular or azygous veins, whereas no control patients had such findings. The Zamboni, or Liberation, procedure involves either angioplasty or stenting of the abnormal vein. Many MS patients are understandably enthusiastic about this theory and treatment.

There are, however, a number of problems with the CCSVI theory that patients and MS neurologists should consider.

  • Diagnostic criteria for CCSVI are not standardized or accepted
  • CCSVI does not seem to explain the distribution of white matter lesions or the relapsing and remitting course that most patients experience
  • CCSVI does not explain the presence of inflammation in MS lesions
  • Iron in MS lesions is contained within macrophages, not erythrocytes or free, as predicted by the CCSVI theory
  • Other diseases with increased venous pressure do not resemble MS
  • Venous drainage is highly redundant, so stricture of a vein usually does not increase venous pressure in the brain
  • Changes in muscle tone or posture from neurological disease may explain some venous blockages; and neurological disease can lead to lower venous blood flow due to circulatory auto regulation

Studies that have been performed to date have not supported the CCSVI theory. Preliminary results from the Buffalo Neuroimaging Analysis Center at the University at Buffalo, The State University of New York, found 56 percent of patients with MS, 42 percent of those with neurological diseases other than MS, and 23 percent of controls met criteria for CCSVI. This group found a decrease in cerebral venous volume in MS patients compared to normal, whereas blockage in venous flow would be expected to induce vascular dilation and increased venous volume.

At the recent ECTRIMS (European Committee for the Treatment and Research of Multiple Sclerosis) meeting in Sweden, groups from Gotteborg, Berlin, Padua, Amsterdam and London found no evidence for venous obstruction in MS patients compared to controls. A study from London, Ontario, found that venous blockage increased with age in both MS and controls. A study from Beirut, Lebanon, found venous changes in only 9 percent of patients after their first MS attack, increasing to 92 percent with advanced MS, possibly suggesting a late finding that is unrelated to the cause of the disease. Nevertheless, as anecdotal reports continue to circulate of individual patients with dramatic responses to treatment of CCSVI, the theory has been of great interest among MS patients and has become the subject of a significant number of studies.

Before CCSVI can be considered as contributing to MS, three criteria should be required.

  1. Venous blockage must be shown to be increased in MS patients relative to healthy controls and other neurological diseases. This would demonstrate an association between CCSVI and MS, but not prove causation.
  2. Treatment of CCSVI should stop the progression of MS symptoms in placebo controlled, blinded, multi-center studies. This would prove that CCSVI contributes to MS, but not prove causation.
  3. MS should develop in humans or animals with venous blockage.

The scientific community is taking CCSVI very seriously. Most of the studies currently under way are testing whether MS patients have venous blockage. The National MS Society and the MS Society of Canada funded seven 24-month studies in June 2010, totaling $2,400,000 of ultrasound, MRI and angiographic techniques to determine whether venous blockage is specific to MS patients in both adult and pediatric populations. The MS Society of Italy is contributing £900,000 (nearly $1.3 million) to study the question. The Buffalo Neuroimaging Analysis Center is conducting a study of venous imaging, as well as a small treatment trial. Saskatchewan and MS Research Australia have also initiated large studies.

The risks of the Liberation procedure in MS are not entirely understood, though stent migration and fatal intracerebral bleeding have already been described. Only controlled studies will teach us the true complication rate. In the meantime, most MS neurologists are recommending that patients await the results of current studies before proceeding with this controversial treatment.


Dr. BowenHow can you justify writing an article that clearly is aimed at debunking CCSVI when you are profiting financially from the many drug companies who would in fact be negatively affected if this new theory is proven? The beauty of the Internet is that everyone now has access to the research data. But you apparently have not done all of your homework. Please dig in a little deeper, keep an open mind, and remember those of us with ms do not have the luxury to wait for trials, and we are very willing to take the chance with a minimally invasive procedure while science catches up and all of the power struggles among disciplines are complete.
Dr. Bowen, My wife's jugular vein operation was about year ago and the results were incredible, way beyond we expected - her MS symptoms disappeared quite totally: - fatique gone- right side of body became normal- spasticy disappeared- balance proplems gone- tension in neck / shoulders goneThis was absolutely best treatment for her. She tried MS drug but that didn't do any good for her. In venography video even I could see the difference in blood flow with right and left jugular. In right the flow was fluent but in left jugular vein the flow was very slow and direction was to the brain.. and the vein was like sort of bag, full of venous blood. But after angioplasty the flow was quite similar to right jugular. Gained benefits have lasted, now allmost year, which is so wonderful. There are MS studies which show that the blood perfusion and flow is decreased in disease. The operation is related to this perfusion problem, fixing it better. Brain needs prober flow, oxygen and nutrition - otherwise there will be s...
Dr. BowenThere is some interesting findings it appears between the university of buffalo team and a large percentage of past studies dealing with volume of blood to the brain. There is of course the well known historic tissue histology and noted inflammation. Then recently the noted high levels of calcium in the brain and tissues for MS patients.I guess i am wondering wouldnt there be a quick test to verify the CCSVI sensitivity for those folks with lesioned or deformed jugular veins with bubble testing as found in a bubble echocardiogram? I would think with many of these patients this could induce blacking out given the pressure change. This i would expect would not occur in normal patients.It would seem the first thing that should be done is to separate out patients based on useable measurement based technologies and see what causal uniformities they show versus other patients over time.Also if the research is accurate on the 3M Tesla NA MRI. Having a followup on these patients at least to the larger vein...
I thought it was very interesting segment I watched on pregnancy and ms. I am 51 years old and was diagnosed with ms 21 years ago. While I was pregnant in my thirties, ms symptoms were non existent. Recently I went on a hormone therapy diet using HCG injections and had the same results as to when I was pregnant. Just wanted to let someone out there know.